Perioperative and periprocedural management of antithrombotic therapy: Multidisciplinar consensus document

Ferrandis Comes, R.; Llau Pitarch, J.V.

doi:10.1016/j.redare.2018.05.002

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Ferrandis Comes, J.V. Llau Pitarch" "autores" => array:2 [ 0 => array:4 [ "nombre" => "R." "apellidos" => "Ferrandis Comes" "email" => array:1 [ 0 => "raquelferrandis@gmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] 2 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "J.V." "apellidos" => "Llau Pitarch" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, Valencia, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital Doctor Peset, Valencia, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Universitat de València, Valencia, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Manejo perioperatorio y periprocedimiento del tratamiento antitrombótico: documento de consenso multidisciplinar" ] ] "textoCompleto" => "The perioperative management of patients receiving anticoagulant and anti-platelet drugs has long been the source of controversy. Antithrombotic therapy is a complex, ever changing and expanding field, which in recent years has seen the emergence of new oral anticoagulant and anti-platelet agents together with new scientific evidence that has changed the traditional way of using “conventional” drugs. This, coupled with the many possible clinical situations that can arise, has greatly diversified antithrombotic management. In order to standardise clinical practice and improve patient care, the Spanish Society of Cardiology took the initiative to create a multidisciplinary consensus document with the help of experts in anticoagulant and anti-platelet drugs from 23 scientific societies involved in the surgical care process.The document, together with its supplementary material, is available in full online and is highly recommended reading.<a class="elsevierStyleCrossRef" href="#bib0050">1</a> It contains all the latest information on the different drugs available, together with a table prepared by the different participating scientific societies establishing the estimated haemorrhagic risk of different types of surgery. This classification was based on the algorithm proposed by the Spanish Consensus Forum of the European Society of Regional Anaesthesia & Pain Therapy (ESRA) on haemostasis-altering drugs,<a class="elsevierStyleCrossRef" href="#bib0055">2</a> which shows how to control bleeding and the clinical implications and consequences of intraoperative haemorrhage.Decisions are conditioned as much by the risk of haemorrhage as the risk of thrombosis, factors inherent to the reason why patients are receiving an antiplatelet or an anticoagulant drug. In the case of antiplatelet drugs, the proposed risk stratification scale is mainly based on the time elapsed since the thrombotic event for which the patient is being medicated, be it an acute myocardial infarction, the placement of a coronary stent, or any other circumstance requiring antiplatelet therapy.<a class="elsevierStyleCrossRefs" href="#bib0060">3,4</a> In the case of anticoagulated patients, the stratification of thrombotic risk is mainly based on the CHADs-Vasc scale for atrial fibrillation stroke risk, the characteristics of the thrombotic event, or the type of valve prosthesis used in the patient.<a class="elsevierStyleCrossRef" href="#bib0070">5</a>The guidelines for the perioperative and periprocedural management of antithrombotic therapy were developed using the latest recommendations from experts. As the document addresses many different aspects in detail, it is not easy to summarise and highlight any particular recommendation. Nevertheless, the guidelines draw attention to some aspects that can be considered essential in routine practice and these merit some comments:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">-In patients receiving anti-platelet therapy, the document recommends maintaining aspirin until the day before surgery in most cases. In patients on long-term aspirin therapy, the drug should be only be suspended when the risk of bleeding outweighs the expected antithrombotic benefit. If an anti-platelet is given as primary prophylaxis, it should be suspended.</li><li class="elsevierStyleListItem" id="lsti0010">-In patients receiving anti-platelets due to a high risk of thrombosis (usually on double anti-platelet therapy), the scheduled surgery should be postponed for as long as necessary to minimise the risk of arterial thrombosis as a result of suspending the therapy.<a class="elsevierStyleCrossRef" href="#bib0075">6</a> In non-urgent procedures that can be deferred, such as hip fracture, there is no need to delay surgery in patients taking thienopyridine derivatives, and the procedure should be scheduled according to the best clinical practice applicable in each case.</li><li class="elsevierStyleListItem" id="lsti0015">-In oral anticoagulation therapy with a vitamin K antagonist, the document questions the need for bridging therapy prior to surgery or an invasive procedure. According to recent studies,<a class="elsevierStyleCrossRef" href="#bib0080">7</a> the systematic administration of a short-acting parenteral anticoagulant such as low-molecular-weight heparin in patients anticoagulated with acenocoumarol or warfarin has a clear tendency to increase bleeding without reducing the incidence of cardioembolic complications. Therefore, this widespread practice should be reserved for very select cases with a high risk of thrombosis.</li><li class="elsevierStyleListItem" id="lsti0020">-The use of direct-acting oral anticoagulants (DOAC) still varies to a large extent, and the consensus document gives the latest recommendations for their perioperative management.<a class="elsevierStyleCrossRefs" href="#bib0085">8,9</a> In general, decisions relating to DOACs should not be based on conventional analytical results, and bridging therapy is not indicated in the great majority of cases. The moment each DOAC is stopped before surgery will depend on the risk of bleeding associated with the surgery and the patient's renal function.</li></ul>We consider it imperative to raise awareness of the importance of this document, which is, at the risk of repeating ourselves, the first consensus document on the management haemostasis-altering drugs endorsed by so many scientific societies. The recommendations have been drafted by a large group of experts, including both prescribers and clinicians who must take the decision to suspend or maintain such drugs before a surgical procedure. We, anaesthesiologists, are the core element of this second group, and the patient's well-being both before and after the surgical intervention is our responsibility. This is why it is so important for us to master the use of these drugs that are so common in surgical patients.Like all guidelines and consensus documents relating to the clinical practice of our specialty, it is essential to implement these recommendations in each hospital in order to raise awareness among anaesthesiologists. This will lead to the creation of protocols that take into account local idiosyncrasies and the specific multidisciplinary implication of each specialty. These recommendations are, naturally, dynamic and subject to constant change. Although the document contains the latest available evidence, the rapid evolution of both medicine and knowledge compels us to constantly be on the lookout for new developments, and this is indeed the commitment that all the authors have assumed.We sincerely hope that this document will be useful to all anaesthesiologists, that it will help standardise the management of antithrombotic therapy, and in doing so improve and unify the healthcare provided to our patients. This is the spirit in which the document has been written." "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Ferrandis Comes R, Llau Pitarch JV. Manejo perioperatorio y periprocedimiento del tratamiento antitrombótico: documento de consenso multidisciplinar. Rev Esp Anestesiol Reanim. 2018;65:423–425." ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "This article is part of the Anaesthesiology and Resuscitation Continuing Medical Education Program. An evaluation of the questions on this article can be made through the Internet by accessing the Education Section of the following web page: <a class="elsevierStyleInterRef" target="_blank" id="intr0005" href="https://www.elsevier.es/redar">https://www.elsevier.es/redar</a>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "<a class="elsevierStyleInterRef" target="_blank" id="intr0010" href="https://doi.org/10.1016/j.recesp.2018.01.001">https://doi.org/10.1016/j.recesp.2018.01.001</a>" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Manejo perioperatorio y periprocedimiento del tratamiento antitrombótico: documento de consenso de SEC, SEDAR, SEACV, SECTCV, AEC, SECPRE, SEPD, SEGO, SEHH, SETH, SEMERGEN, SEMFYC, SEMG, SEMICYUC, SEMI, SEMES, SEPAR, SENEC, SEO, SEPA, SERVEI SECOT y AEU" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "D. 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ISSN: 2341-1929

Revista Española de Anestesiología y Reanimación (REDAR) -the Spanish Journal of Anesthesiology and Resuscitation- is the scientific body of the Spanish Society of Anesthesiology, Resuscitation and Pain Therapy. This is a monthly journal (10 issues) that publishes scientific articles of all areas within its specialty: clinical anesthesia, resuscitation-intensive medicine and critical care, diagnosis and treatment of acute and chronic pain, urgent care and emergencies and studies on basic science and related fields. The journal accepts work in both Spanish and English.

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Vol. 65. Issue 8.